FLORIDA DEPARTMENT OF STATE (1) Name (2) Address (number and street) City, State, Zip Code
CHECK IF ADDRESS HAS CHANGED
DIVISION OF ELECTIONS
OFFICE USE ONLY
CAMPAIGN TREASURER'S REPORT SUMMARY
(3)
ID Number:
(4)
Check appropriate box(es): Candidate (office sought): Political Committee Committee of Continuous Existence Party Executive Committee Electioneering Communication
CHECK IF PC HAS DISBANDED CHECK IF CCE HAS DISBANDED CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED
(5) REPORT IDENTIFIERS Cover Period: Original (6) From Amendment / / To / / Report Type Independent Expenditure Report EXPENDITURES THIS REPORT
Special Election Report (7)
CONTRIBUTIONS THIS REPORT
Cash & Checks Loans Total Monetary In-Kind
$ $ $ $
Monetary Expenditures
$
Transfers to Office Account $ Total Monetary
$
(8)
Other Distributions
$
(9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date
$
$
(11) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.)
I certify that I have examined this report and it is true, correct, and complete.
(Type name) Individual (only for electioneering commun.) Treasurer Deputy Treasurer
I certify that I have examined this report and it is true, correct, and complete.
(Type name) Candidate Chairperson (only for PC, PTY & electioneering commun. organization)
X
Signature
DS-DE 12 (Rev. 08/04)
X
Signature
print
reset
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT SUMMARY
(1) (2) (3) (4) Type full name of candidate, political committee, committee of continuous existence, party executive committee, or individual or organization filing an electioneering communication report. Type the address (include city, state, and zip code). You may use a post office box. If the address has changed since the last report filed, check the appropriate box. Type identification number assigned by the Division of Elections. Check one of the appropriate boxes: Candidate (type office sought - include district, circuit, or group numbers) Political Committee Committee of Continuous Existence Party Executive Committee Electioneering Communication If PC or CCE has disbanded and will no longer file reports, check appropriate box. If individual or organization will no longer file electioneering communication reports, check appropriate box. Type the cover period dates (e.g., From 07/01/03 To 09/30/03) Enter the report type using one of the following abbreviations (see Calendar of Election and Reporting Dates). If report is for a special election, add “S” in front of the report code (e.g., SG3).
Quarterly Reports January Quarterly........................................................... Q4 April Quarterly ................................................................ Q1 July Quarterly ................................................................. Q2 October Quarterly........................................................... Q3 Primary Reports 32nd Day Prior..................................................................F1 18th Day Prior ..................................................................F2 4th Day Prior ....................................................................F3
th
(5)
General Election Reports 46 Day Prior .................................................................G1 32nd Day Prior ................................................................G2 18th Day Prior .................................................................G3 4th Day Prior ...................................................................G4 90-Day Termination Reports (Candidates Only) Termination Report ........................................................TR
Check one of the appropriate boxes: Original (first report filed for this reporting period) Amendment (an amendment to a previously filed report) Special Election Report Independent Expenditure Report (see Section 106.071, F.S.) (6) Type the amount of all contributions this report: Cash & Checks Loans Total Monetary (sum of Cash & Checks and Loans) In-kind (a fair market value must be placed on the contribution at the time it is given) Type the amount of all expenditures this report: Monetary Expenditures Transfers to Office Account (elected candidates only) Total Monetary (sum of Monetary Expenditures and Transfers to Office Account) Type the amount of other distributions (goods & services contributed to a candidate or other committee by a PC, CCE or PTY). Type the amount of TOTAL monetary contributions to date (parties keep cumulative totals for 2 year periods at a time (e.g., 01/01/02 – 12/31/03). Candidates keep cumulative totals from the time the campaign depository is opened through the termination report). Type the amount of TOTAL monetary expenditures to date (parties keep cumulative totals for 2 year periods at a time (e.g., 01/01/02 – 12/31/03). Candidates keep cumulative totals from the time the campaign depository is opened through the termination report). Type or print the required officer’s name and have them sign the report: Candidate report (treasurer & candidate must sign) PC report (treasurer & chairperson must sign) CCE report (treasurer must sign) PTY report (treasurer & chairperson must sign) Electioneering Communication report (individual or organization’s treasurer & chairperson must sign)
(7)
(8) (9)
(10)
(11)
AMENDMENT REPORTS: An amendment report summary should summarize only contributions, expenditures, distributions, & fund transfers being reported as additions or deletions. Read the instructions for the sequence number & amendment type fields on the back of forms DS-DE 13, 14, 14A and 94. The Division will summarize all reports submitted for each reporting period and for the filer to date.